Endotracheal Mechanical Ventilation Research Articles

Albuterol as an adjuvant in acute anticholinesterase pesticide poisoning: a randomized, placebo-controlled clinical trial.

Acute anticholinesterase pesticide poisoning is a serious clinical problem, particularly in developing countries. Atropine is the most acceptable treatment for acute anticholinesterase poisoning. However, it only stops fluid production. Albuterol is a beta-2 receptor agonist that can increase fluid removal and speed the return of effective oxygen exchange. This study aims to evaluate the safety and efficacy of nebulized albuterol as an adjuvant therapy in patients with acute anticholinesterase poisoning. This stratified block randomized, single-blinded, placebo-controlled, parallel-group clinical trial was conducted between November 2020 and October 2021. It enrolled 80 patients with acute anticholinesterase pesticide poisoning who were admitted to Tanta University Poison Control Center. Patients were allocated into two groups (40 patients each). The strata were based on the severity of poisoning (moderate and severe). Patients in group I received 10mg of nebulized albuterol. Group II received an equivalent volume of nebulized normal saline. Additionally, standard treatment was provided to both groups. Outcomes included oxygenation, mortality, need for endotracheal intubation and mechanical ventilation, hospital stay duration, time to atropinization, and total doses of atropine and oxime. We found insignificant differences in sociodemographics, exposure characteristics, clinical manifestations, or routine laboratory tests between the studied groups. The median values of oxygen saturation by pulse oximetry were 99% in the albuterol moderate toxicity group and 98% in the control moderate toxicity group. Albuterol significantly improved oxygen saturation in moderate intoxicated patients (P=0.039). Therefore, nebulized albuterol is a safe drug. Moreover, it may improve oxygenation in acute anticholinesterase pesticide poisoning.

Randomized controlled trial to evaluate the rate of successful neonatal endotracheal intubation performed with a stylet versus without a stylet.

Neonates in intensive care units often require endotracheal intubation and mechanical ventilation. During this intubation procedure, a stylet is frequently used along with an endotracheal tube. Despite the widespread use of a stylet, it is still not known whether its use increases the intubation success rate. This study examined the association between stylet use and the intubation success rate in surgical neonates. This single-center study was conducted between December 2021 and December 2022 in the Neonatal surgical intensive care unit of a tertiary care center in Northern India. Infants were randomized to have the endotracheal intubation procedure performed using either an endotracheal tube alone or with a stylet. The primary outcome of the study was to assess the successful first-attempt neonatal endotracheal intubation rate with and without using a stylet. Apart from the rate of successful intubation, the duration of the intubation and complications during the intubation procedures as measured by bradycardia, desaturation episodes, and local trauma were also recorded. Both groups were thus compared on above mentioned outcomes. The total number of neonates enrolled were 200, and the overall success rate (81% in the stylet group vs. 73% in the non-stylet group) was not statistically significant. Intubation time was however less, when stylet was used (16.2 ± 4.3 vs. 17.5 ± 5.0 s, p = .046). When the endotracheal tube size was 3 or less, the success rate was substantially higher in the stylet group (80%) than the non-stylet group (63%), p = .03. No statistical difference was recorded for bleeding and local trauma, though the esophageal intubation rate was higher when intubation was attempted without the stylet. Endotracheal intubation using a stylet did not significantly improve the success rate of the procedure, however, intubation time significantly varied between groups and in different conditions. The rigidity and curvature provided by the stylet may facilitate the process of intubation when smaller caliber endotracheal tubes are used.

Tracheostomy in Critically Ill Covid 19 Patients: A Review of Outcome

The novel human coronavirus disease (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which can result in serious respiratory illness requiring endotracheal intubation, mechanical ventilation, and tracheostomy. Resources on the indication, ideal timing and outcomes for tracheostomy in COVID-19 patients are still limited. Tracheostomy is an aerosol generating procedure with risk of transmission of airborne disease to healthcare workers (HCWs)1. However, tracheostomy aids in ventilation liberation2 for mechanical ventilated patient in general but resources on overall outcome for tracheostomy in COVID-19 patients are not well reported. Thus, a trained surgeon, adequate safety equipment and measures are essential to reduce timing of exposure through this aerosol-generating procedures and reduce risk of complications.

Development and validation of a novel poisoning agitation-sedation score for predicting the need for endotracheal intubation and mechanical ventilation in acutely poisoned patients with disturbed consciousness.

Accurate assessment of disturbed consciousness level (DCL) is crucial for predicting acutely poisoned patients' outcomes. Development of a novel Poisoning Agitation-Sedation Score (PASS) to predict the need for endotracheal intubation (ETI) and mechanical ventilation (MV) in acutely poisoned patients with DCL. Validation of the proposed score on a new set of acutely poisoned patients with DCL. This study was conducted on 187 acutely poisoned patients with DCL admitted to hospital from June 2020 to November 2021 (Derivation cohort). Patients' demographics, toxicological data, neurological examination, calculation of the Glasgow Coma Scale (GCS), Full Outline of Unresponsiveness (FOUR) score, Richmond Agitation-Sedation Scale (RASS), and outcomes were gathered for developing a new score. The proposed score was externally validated on 100 acutely poisoned patients with DCL (Validation cohort). The PASS assessing sedation consists of FOUR (reflexes and respiration) and GCS (motor) and provides a significantly excellent predictive power (AUC = 0.975) at a cutoff ≤9 with 100% sensitivity and 92.11% specificity for predicting the need for ETI and MV in sedated patients. Additionally, adding RASS (agitation) to the previous model exhibits significantly good predictive power (AUC = 0.893), 90.32% sensitivity, and 73.68% specificity at a cutoff ≤14 for predicting the need for ETI and MV in disturbed consciousness patients with agitation. The proposed PASS could be an excellent, valid and feasible tool to predict the need for ETI and MV in acutely poisoned disturbed consciousness patients with or without agitation.

Hemi-diaphragmatic paralysis

Introduction: Diaphragmatic paralysis (DP) involving the phrenic nerve is related to brachial plexus injury in 80–90% of the cases. Other causes include iatrogenic procedure involving the cardiopulmonary area. It causes respiratory distress which can be severe requiring prolonged need for respiratory support. Recovery can be spontaneous, typically by the first 6–12 months of life though some infants may require surgical intervention if no improvement in DP is noted by 1–2 months of life in the setting of compromised quality of life. Case Report: We present a preterm infant, 31 completed weeks of gestational age, birth weight 1440 g born via emergency C-section due to preterm labor in breech presentation. During delivery, the patient suffered a left brachial plexus injury with phrenic nerve involvement. He developed respiratory distress requiring endotracheal intubation and mechanical ventilation. His clinical course involved multiple failed extubation attempts. Chest X-ray (CXR) and chest fluoroscopy confirmed the diagnosis of left hemi-diaphragmatic paralysis. The patient had a prolonged respiratory support course but was finally weaned to room air by three months of age. Conclusion: Preterm infants can sustain perinatal brachial plexus injury like term or near-term infants in the setting of a traumatic birth irrespective of birth weight. The time and indications for conservative (non-surgical) versus surgical intervention remains debatable. Each case should be tailored to the child’s severity of injury and quality of life and growth. Clinical recovery can occur even with considerable persistence weakness on radiography or chest ultrasound.

Effectiveness of Swallowing and Oral Care Interventions on Oral Intake and Salivary Flow of Patients Following Endotracheal Extubation at a Tertiary Care Center: A Randomized Controlled Trial.

Endotracheal intubation and mechanical ventilation are the most frequently used life-sustaining interventions in critical care. Prolonged intubation can lead to post-extubation dysphagia, affecting the individual's nutritional level and communication ability. Thereupon, this study aims to assess the effectiveness of swallowing and oral care interventions in resuming oral intake and increasing salivary flow in post-extubation patients. A randomized controlled trial was conducted in critical care units of a tertiary care setting, where 92 post-extubation patients who had undergone intubation for≥48 hours were enrolled. The intervention group received swallowing and oral interventions, including safe swallowing education (SSE), toothbrushing, salivary gland massage, oral cavity, and swallowing exercises. In contrast, the control group received standard oral care every 8th hour. Oral intake was assessed daily with the Functional Oral Intake Scale, and the salivary flow measurement was assessed with oral Schirmer's test on the 1st, 3rd, and 7th day after extubation. The baseline demographic and clinical characteristics showed that the groups were homogenous. The intervention group achieved total oral intake two days earlier than the control group. Findings also showed that the participants in the intervention group had a significant increase in salivary flow than in the control group on the 3rd and 7th days of the intervention. Swallowing and oral care interventions help post-extubation patients resume early oral intake and increase salivary flow after prolonged intubation. Hence, it improves the patient's outcome toward a healthy life.

Insights regarding in-hospital outcomes of COVID-19 hospitalisations and co-existing premature ventricular contractions : from national inpatient sample 2020

Abstract Introduction Since the emergence of the COVID-19 pandemic, several reports have highlighted COVID-19 infection's arrhythmogenic consequences on the cardiac conduction system (1). SARS-CoV-2 has a well-established predilection to cardiomyocytes and is associated with myocardial injury with worse predicted outcomes. A wide range of electrocardiographic findings was significantly associated with COVID-19 infection (2). However, literature is scarce on the outcomes of such ECG findings, and its implications are yet to be understood. Purpose We sought to illustrate the significant outcomes of patients hospitalised for COVID-19 infection and premature ventricular contractions. Methods The National Inpatient Sample database (NIS) - 2020 was analysed to identify adult hospitalisations with a primary diagnosis of COVID-19 with or without co-existing premature ventricular contractions (PVC) using International Classification of Diseases – 10 Clinical Modification (ICD-10-CM) codes. The primary outcome was inpatient mortality, while secondary outcomes included inpatient morbidity, mean length of stay (LOS), and mean total hospital charge (THC). Multivariate logistic regression and linear regression analyses were used to adjust for possible confounders. Results Out of 1,050,045 COVID-19 hospitalisations, 7,729 (0.73%) had PVCs. Encounters with COVID-19 and co-existing PVCS had higher adjusted odds of inpatient mortality (Adjusted odds ratio [aOR]: 1.18, 95% confidence interval [CI]: 1.014-1.38, p=0.033), longer mean LOS of 1.8 days (95% CI: 1.4-2.3, p <0.001), and higher mean THC of $21,869 (95% CI: $13,902-$29,835, p <0.001) than those without co-existing PVCs. Figure 1 shows a forest plot illustrating the multivariate analysis of in-hospital morbidities when adjusted for patient demographics, comorbidities, and hospital characteristics. Conclusion Among patients hospitalised with COVID-19 infection, those with premature ventricular contractions had worse outcomes regarding in-hospital mortality, sepsis, need for endotracheal intubation, mechanical ventilation, and vasopressors use, in addition to the longer length of hospital stay, and higher total hospital charges. Although PVCs are commonly encountered in hospitalised patients and often require no medical interventions in most cases, they are associated with poor prognosis in patients with COVID-19 infection.Forest plot for adjusted outcomes

INFLUENCE OF OBESITY ON DIFFICULTY OF RUNNING CORONAVIRUS DISEASE (COVID-19) (clinical case)

Aim: To conduct a retrospective analysis of the influence of obesity on the severity of the course of COVID-19 based on the analysis of the chart of an inpatient who was treated in the infectious department of the Chernivtsi Regional Clinical Hospital.
 Materials and methods. "Medical card of an inpatient" of a patient who was undergoing inpatient treatment in the infectious department of the Chernivtsi Regional Clinical Hospital.
 Results. A 42-year-old obese patient (BMI 40.0 kg/m2) was admitted to the inpatient ward of the infectious disease department of the Chernivtsi Regional Clinical Hospital on the 5th day of her illness. In hospital conditions, oxygen therapy was immediately started (flow 3 l/min), antibiotic therapy (cefepime - 1 g 3 r/day), hormone therapy (dexamethasone - 8 mg 1 r/day) was prescribed. On the 26th day of intensive treatment, the patient's condition significantly worsened. The state of consciousness was disturbed to the level of sopor, and then came a coma. Hemodynamic instability was noted, which required medical support (dopamine). The patient underwent endotracheal intubation and mechanical ventilation. Despite all the measures applied, cardiac arrest occurred. The resuscitation measures that were carried out did not have the desired effect, and the death of the patient was confirmed.
 Conclusion. In patients with obesity (BMI > 40), the course of COVID-19 is much more severe, compared to patients whose body weight is within acceptable norms. Also, excess body weight significantly increases the risk of complications in patients with COVID-19 caused by Sars-Cov2, and more often leads to a fatal outcome.

Herramientas docentes en medicina intensiva: chatGPT

Asthma exacerbations can be life-threatening, with 25,000 to 50,000 such patients per year requiring admission to an ICU in the United States. Appropriate triage of life-threatening asthma is dependent on both static assessment of airway function and dynamic assessment of response to therapy. Treatment strategies focus on achieving effective bronchodilation with inhaled β2-agonists, muscarinic antagonists, and magnesium sulphate while reducing inflammation with systemic corticosteroids. Correction of hypoxemia and hypercapnia, a key in managing life-threatening asthma, occasionally requires the incorporation of noninvasive mechanical ventilation to decrease the work of breathing. Endotracheal intubation and mechanical ventilation should not be delayed if clinical improvement is not achieved with conservative therapies. However, mechanical ventilation in these patients often requires controlled hypoventilation, adequate sedation, and occasional use of muscle relaxation to avoid dynamic hyperinflation, which can result in barotrauma or volutrauma. Sedation with ketamine or propofol is preferred because of their potential bronchodilation properties. In this review, we outline strategies for the assessment and management of patients with acute life-threatening asthma focusing on those requiring admission to the ICU.

Characteristics and Outcomes of Critically Ill Patients With Pulmonary Hypertension Who Undergo Endotracheal Intubation and Mechanical Ventilation.

Background: Patients with pulmonary hypertension (PH) who undergo endotracheal intubation have an increased risk of adverse outcomes, but little is known regarding prognostic factors and there is limited evidence to guide management. We sought to define characteristics, prognostic factors, and outcomes of critically ill patients with PH who underwent intubation. Study Design: We performed a single-center retrospective cohort study of critically ill patients with group 1, 3 or 4 PH who underwent intubation. Results: Eighty-one patients were included. Patients had a median age of 56 years (interquartile range 44-65) and were predominantly female (n = 53, 65%) and Caucasian (n = 71, 88%). Forty-five (56%) had group 1 PH while 25 (31%) had group 3 PH and 11 (14%) had group 4 PH. Patients were admitted to the hospital for right ventricular failure (n = 21, 25.6%), sepsis (n = 18, 22.2%), and respiratory failure (n = 19, 23.1%). Hypoxemic respiratory failure (n = 54, 66.7%) was the most common indication for intubation. In-hospital mortality was 30.9% and 1-year mortality was 48.2%. All patients (11 of 11, 100%) intubated electively for intensive care unit procedures survived to hospital discharge while only 1 of 6 (16.7%) intubated in the setting of a cardiac arrest survived. After adjusting for right ventricular systolic pressure, pre-intubation PaO2 (odds ratio [OR] = 0.99, 95% confidence interval [CI] 0.97-1.00, P = .02) and postintubation PaO2 (OR = 0.97 per 1mm Hg, 95% CI 0.95 to 0.99, P = .003), pH (OR = 0.49 per 0.1 increase, 95% CI 0.29 to 0.80, P = .005) and PaCO2 (OR = 1.08 per 1mm Hg, 95% CI 1.02 to 1.14, P = .005) were significantly associated with in-hospital mortality. Results were similar when we excluded patients intubated electively or in the setting of cardiac arrest. Conclusions: Intubation in critically ill patients with PH is associated with significant in-hospital mortality and nearly 50% 1-year mortality. Potentially modifiable factors, such as peri-intubation gas exchange, are associated with an increased risk of death while other demographic and hemodynamic variables are not.

Sensitivity and specificity of phrenic nerve electrophysiology to predict mechanical ventilation in the Guillain-Barré syndrome.

In Guillain-Barré syndrome (GBS), the sensitivity and specificity of phrenic compound muscle action potential (CMAP) measurements to predict endotracheal mechanical ventilation are unknown. Hence, we sought to estimate sensitivity and specificity. We performed a 10-year retrospective analysis of adult GBS patients from our single-center laboratory database (2009 to 2019). The phrenic nerve amplitudes and latencies before ventilation were recorded along with other clinical and demographic features. Receiver operating curve (ROC) analysis with area under the curve (AUC) was used to determine the sensitivity and specificity with 95% confidence interval (CI) for phrenic amplitudes and latencies in predicting the need for mechanical ventilation. Two hundred five phrenic nerves were analyzed in 105 patients. The mean age was 46.1 ± 16.2 years, with 60% of them being male. Fourteen patients (13.3%) required mechanical ventilation. The average phrenic amplitudes were lower in the ventilated group (P = .003), but average latencies did not differ (P = .133). ROC analysis confirmed that phrenic amplitudes could predict respiratory failure (AUC = 0.76; 95% CI, 0.61 to 0.91; P < .002), but phrenic latencies could not (AUC = 0.60; 95% CI, 0.46 to 0.73; P = .256). The best threshold for amplitude was ≥0.6 mV, with sensitivity, specificity, and positive and negative predictive values of 85.7%, 58.2%, 24.0%, and 96.4%, respectively. Our study suggests that phrenic CMAP amplitudes can predict the need for mechanical ventilation in GBS. In contrast, phrenic CMAP latencies are not reliable. The high negative predictive value of phrenic CMAP amplitudes ≥0.6 mV can preclude mechanical ventilation, making these a useful adjunct to clinical decision-making.

PO-04-156 INSIGHTS REGARDING OUTCOMES FOR COVID-19 HOSPITALIZATIONS WITH ADULT CONGENITAL HEART DISEASE (ACHD)

As of December 2022, SARS-CoV-2 coronavirus resulted in over 6 million deaths worldwide.[1] It was realized early into the pandemic, that COVID-19 significantly impacts the Cardiovascular system. [2] Patients with pre-existing cardiovascular comorbidities were particularly at higher risk of adverse outcomes during their hospitalizations. [3] Similarly, it can be safe to assume patients with adult congenital heart disease (ACHD) should considered a high-risk population for the development of severe COVID infection with increased rates of significant cardiovascular complications. Based on this reasoning and the paucity of data available on this topic using a large database, we sought to investigate the outcomes of patients with ACHD who were admitted to the hospital with COVID-19. The National Inpatient Sample database for 2020 was queried to identify adult hospitalizations with a primary diagnosis of COVID-19 and a secondary diagnosis of ACHD using International Classification of Diseases – 10 Clinical Modification (ICD-10-CM) codes. The primary outcome studied was inpatient mortality, while secondary outcomes included inpatient complications, mean length of stay (LOS), and total hospital charge (THC). Multivariate logistic and linear regression analyses were used to adjust for possible confounders and analyze the variables. Out of 1,050,045 COVID-19 hospitalizations registered, 2,425 (0.23%) had ACHD as a secondary diagnosis. Encounters with ACHD who were hospitalized with COVID-19 had significantly higher adjusted odds of inpatient mortality (Adjusted Odds Ratio [aOR]: 1.4, [95% CI: 1.05-1.88], p=0.022), Longer LOS (Mean 2.4 days, [95% CI: 1.35-3.40], p <0.001), and higher Total Hospital Charges (Mean $53,000, [95% CI: 20811-85190], p <0.001). A Forrest plot (Figure 1) demonstrates a graphical representation of the multivariate analysis of the significant in-hospital complications when adjusted for patient demographics, comorbidities, and hospital characteristics. Among COVID-19 hospitalizations, those with a history of congenital heart diseases had significantly worse outcomes in terms of in-hospital mortality, sepsis; the need for endotracheal intubation, mechanical ventilation, and vasopressors; developing acute kidney injury and pulmonary embolism, in addition to the longer length of stay, and higher total hospital charges.

Correlation between high-resolution computed tomography appearance and histopathological features in the diagnosis of interstitial lung diseases. A real-life study.

According to current guidelines, a surgical biopsy is rarely required when a high-confidence radiologic interstitial lung disease (ILD) diagnosis is made on thin-section high-resolution computed tomography (HRCT). Nevertheless, disowning HRCT scans diagnosed by biopsy are more common than presumed. Our study aimed to describe the concordance rate between HRCT scans and pathological diagnoses of ILDs obtained by surgical biopsy. The current guideline suggests the use of surgical lung biopsy (SLB) in patients with newly detected ILD of unknown cause. Patients who underwent mini-invasive surgical biopsies for interstitial lung diseases from January 2018 to August 2022 were analyzed. The HRCT scans were reviewed by an observer blinded to the patient's clinical information. The concordance between histological and HRCT-scan were assessed. Data from 104 patients with uncertain low confidence diagnosis of interstitial lung diseases at HRCT were analyzed. Most of the patients are male (65; 62.5%). The more frequent HRCT pattern were: alternative diagnoses (46; 44.23%), UIP probable (42; 40.38%), UIP indeterminate (7; 6.73%), and non-specific interstitial pneumonia (NSIP) (9, 8.65%). The more common histological diagnosis was UIP definite (30; 28.84%), hypersensitivity pneumonia [HP](19; 18.44%), NSIP (15; 14.42%), sarcoidosis (10; 9.60%). In 7 (20%) cases, the final pathological finding denies HRCT-scans diagnoses; indeed, a moderate agreement was observed between HRCT-scan findings and the definitive histological diagnosis (kappa index: 0.428). HRCT-scan has limitations if the objective is to define interstitial lung diseases accurately. Consequently, pathological assessment should be taken into account in order to provide more accurate tailored treatment strategies because the risk is to wait from 12 to 24 months to ascertain if the ILD will be treatable as progressive pulmonary fibrosis (PPF). Undeniably true, video-assisted surgical lung biopsy (VASLB) with endotracheal intubation and mechanical ventilation is associated with a risk of mortality and morbidity that is far from nil. Nevertheless, in recent years a VASLB approach performed in awake subjects under loco-regional anesthesia (awake-VASLB) has been suggested as an effective method to obtain a highly confident diagnosis in patients with diffuse pathologies of the lung parenchyma.

Tracheal resection in post COVID-19 patients is associated with high reintervention rate and early restenosis.

A remarkable increase in the number of patients presenting with tracheal complications after prolonged endotracheal intubation and mechanical ventilation for the management of the severe COVID-19 - associated respiratory failure has been observed. In this study, we assessed the postoperative outcomes of tracheal resection in COVID-19 patients. We conducted a retrospective study in which all patients with a history of prolonged invasive mechanical ventilation due to COVID-19 infection, who were treated with tracheal resection and reconstruction, were included. The primary objective was in-hospital mortality and postoperative reintervention rate. The secondary objective was the time to tracheal restenosis. During the 16-month study period, 11 COVID-19 patients with tracheal complications underwent tracheal resection with end-to-end anastomosis. Mean patient age was 51.5 ± 9 years, and the majority were male (9 patients). Eight patients were referred for management of post-intubation tracheal stenosis and 3 for tracheoesophageal fistula. Eight patients had a history of tracheostomy during the COVID-19 infection hospitalization. There was one in-hospital death (9.1%) due to septicemia in the Intensive Care Unit, approximately two months after the operation. Postoperatively, 32 reinterventions were required for tracheal restenosis due to granulation tissue formation. The risk for reintervention was higher during the first 3 months after the index operation. Four patients developed tracheal restenosis (36.4%) and two of them required endotracheal stent placement during the follow up period. Tracheal resection and reconstruction after COVID-19 infection is associated with a high reintervention rate postoperatively. Such patients require close follow up in expert interventional pulmonology units and physicians should be on high alert for the early diagnosis and optimal management of tracheal restenosis.

THORACIC SEGMENTAL SPINAL ANAESTHESIA/ GENERAL ANAESTHESIA FOR LAPROSCOPY SURGERY

Background:Laparoscopic surgeries are usually done under general anesthesia, but many patients with major medical problems sometimes cannot tolerate such anesthesia, and thoracic spinal anesthesia may be beneficial in such patients. A comparative study between two groups of patients using either general anesthesia or segmental thoracic spinal anesthesia. Aim &amp; objectives:The aim of this study is to compare mean hospital stay, patient, and surgeon satisfaction between two groups of healthy patients operated for various laparoscopic surgeries under general and segmental thoracic spinal anesthesia. Study period&amp;place:December 2022-January2023 ( 1 month),in Narendra Modi Medical collage&amp; L.G hospital,Ahmedabad. Patients and methods:Thirty adult patients of ASA I or II grade undergoing various laparoscopic surgeries, randomly divided into two groups of 15 patients each. Group G received conventional general anesthesia with endotracheal intubation and mechanical ventilation through Drager Fabious GS workstation.Group S received a segmental (T 7-8 inj.) thoracic spinal anesthesia using 1 .5ml of plain levobupivacaine 0.5% (7.5 mg) in addition to 25 μg fentanyl. In group G,after pneumoperitoneum for haemodynamic changes( hypertension,tachycardia) iv fentanyl alliquotes,increase sevoflurane concentration,needed.In cases not responding to them inj.Nitroglycerin infusion was given. In group S, drugs to manage patient anxiety or hemodynamic fluctuations (bradycardia or hypotension) were given when needed. Intraoperative haemodynamic monitoring, postoperative pain, complications, recovery time by modified alderte score&gt;8 and patient &amp; surgeon satisfaction,mean hospital stay were compared between the two groups. Results: In the GroupS, spinal anesthetia was performed easily in all 15 patients, although two complained of paresthesia, which respondedto slight needle withdrawal the block was effective for surgery in all patients, and five experienced some discomfort, shoulder pain which was readily treated with small doses of fentanyl, but none required conversion to general anesthesia five patients required midazolam for anxiety, six patients required mephentermine and atropine for hypotension and bradycardia, and recovery was uneventful and without sequelae. In group G,3(20%) patients required infusion of Nitroglycerin for hypertension&amp; 5(33%) patient required 2 times fentonyl alliquotes of 50 mcg iv.,3(20%) patients required increase concentration of sevoflurane ( upto 5%) Conclusion: Patients of Thoracic segmental spinal anesthesia group had shorter discharge time( time to achieve modified alderte acore&gt;8) and better patient satisfaction. Surgeon satisfaction was higher in general anesthesia group. Segmental thoracic spinal anesthesia can be used successfully and effectively for laparoscopic surgery.

REVIEW OF SURFACTANT DELIVERY STRATEGIES IN NEONATOLOGICAL PRACTICE

Administration of surfactant by minimally invasive techniques that promote spontaneous breathing may be safer and more effective than administration with endotracheal intubation and mechanical ventilation. At present, the use of INSURE and LISA/MIST methods is well researched and widely used, their effectiveness has been largely proven and beyond doubt. However, current trends towards greater use of non-invasive respiratory support in surfactant-deficient preterm infants have created a demand for similar non-invasive methods of administering exogenous surfactant, one of which is the potentially promising method of inhaled delivery of a substance to the lungs using a nebulizer.

Rapid evaluation of the early pathogen of severe Chlamydophila psittaci pneumonia by diagnostic bronchoscopy

To explore the rapid evaluation of the early pathogen of severe Chlamydophila psittaci pneumonia by bedside diagnostic bronchoscopy, so as to start effective anti-infection treatment before the results of macrogenome next generation sequencing (mNGS) test. The clinical data of three patients with severe Chlamydophila psittaci pneumonia who were successfully treated in the First Affiliated Hospital of Xinjiang Medical University, the First People's Hospital of Aksu District, and the First Division Hospital of Xinjiang Production and Construction Corps from October 2020 to June 2021 were retrospectively analyzed, including the rapid assessment of early pathogens by bedside diagnostic bronchoscopy and the use of antibiotics to start anti-infection treatment. These patients were successfully treated. The three patients were male, aged 63, 45 and 58 years old, respectively. Before the onset of the penumonia, they had a clear medical history of bird exposure. The clinical manifestations mainly included fever, dry cough, shortness of breath and dyspnea. One case had abdominal pain and lethargy. The results of laboratory examination indicated that the peripheral blood white blood cell count (WBC) of two patients were high [(10.2-11.9)×109/L], the percentage of neutrophils increased (85.2%-94.6%) and the percentage of lymphocytes decreased (3.2%-7.7%) in all 3 patients after admission to hospital and entering into intensive care unit (ICU). The procalcitonin (PCT) of 3 patients increased after admission, and still increased when entering ICU (0.3-4.8 ng/L), so did C-reactive protein (CRP, 58.0-162.0 mg/L) and erythrocyte sedimentation rate (ESR, 36.0-90.0 mm/1 h). After admission, serum alanine transaminase (ALT) increased in 2 cases (136.7 U/L, 220.5 U/L), so did aspartate transaminase (AST) in 2 cases (249.6 U/L, 164.2 U/L). ALT (162.2-267.9 U/L) and AST (189.8-223.2 U/L) increased in 3 patients when they entered ICU. The level of serum creatinine (SCr) of 3 patients were normal after admission and entering ICU. The chest computed tomography (CT) findings of 3 patients were acute interstitial pneumonia, bronchopneumonia and lung consolidation, of which 2 cases were accompanied by a small amount of pleural effusion, and 1 case was accompanied by more regular small air sacs. Multiple lung lobes were involved, but mainly one lung lobe. The oxygenation index (PaO2/FiO2) of the 3 patients admitting to ICU were 100.0, 57.5 and 105.4 mmHg (1 mmHg ≈ 0.133 kPa), respectively, which met with the diagnostic criteria of moderate and severe acute respiratory distress syndrome (ARDS). All three patients received endotracheal intubation and mechanical ventilation. Under the bedside bronchoscope, the bronchial mucosa of 3 patients were obviously congested and edematous, without purulent secretion, and there was 1 case with mucosal hemorrhage. Three patients underwent bedside diagnostic bronchoscopy, and the evaluation result of the pathogen was that it might be atypical pathogen infection, so they were given moxifloxacin, cisromet and doxycycline intravenously, respectively, and combined with carbapenem antibiotics intravenously. After 3 days, the detection results of mNGS in bronchoalveolar lavage fluid (BALF) showed that only Chlamydia psittaci was infected. At this time, the condition was significantly improved, and PaO2/FiO2 was significantly increased. Therefore, the antibiotic treatment scheme remained unchanged, and mNGS only served to verify the initial diagnosis. Two patients were extubated on the 7th and 12th day of admission to the ICU, respectively, while one patient was extubated on the 16th day of admission to the ICU due to nosocomial infection. All 3 patients were transferred to the respiratory ward after the condition was stable. The bedside diagnostic bronchoscopy based on clinical characteristics is conducive to not only the rapid assessment of the early pathogens of severe Chlamydia psittaci pneumonia, but also effective anti-infection treatment before the returning of mNGS test results, which can make up for the lag and uncertainty of the mNGS test results.

A Comparison of General anesthesia and segmental thoracic Spinal Anesthesia regarding hemodynamic and respiratory stability for laparoscopic cholecystectomy

Background: Laparoscopic Cholecystectomy (LC) is conventionally performed under general anaesthesia (GA), but multiple studies have found spinal anaesthesia (SA) as a safe alternative. GA may be associated with postoperative pain and nausea and vomiting (PONV) and the use of neuraxial techniques for a variety of surgical procedures resulted in a decrease in mortality, venous thromboembolism, myocardial infarction, and several other complications. Spinal anesthesia (SA) is a commonly used anaesthesia technique that has a very good safety profile. Methods: This is a prospective study conducted in the Department of Anesthesia at Goa Medical College, Goa from June 2021 to May 2022. Ninety patients classified according to the American Society of Anesthesiology (ASA) as class I or II undergoing laparoscopic cholecystectomy, divided into two groups, 45 patients each. Written informed consent was taken from each patient before the study. Group A received conventional general anesthesia with endotracheal intubation and mechanical ventilation, and Group B received a segmental T10- T11 interspace thoracic spinal anesthesia using 1 ml of plain bupivacaine 0.5% (5 mg) in addition to 25 mcg fentanyl. In group B, drugs to manage patient anxiety or hemodynamic perturbations (bradycardia or hypotension) were given when needed. Result: Group B, receiving segmental thoracic spinal anesthesia, was more hemodynamically stable as compared to Group A. All three hemodynamic parameters pulse rate, systolic blood pressure, and diastolic blood pressure were elevated throughout the procedure in the GA group. Bradycardia was seen in 2 and hypotension in 5 cases in the Group B group. The surgeons did not find any significant difference in the operating conditions or muscle relaxation between the two groups. Patients in both groups maintained above 97-98% SPO2. Conclusion: Segmental Thoracic Spinal anesthesia is adequate and safe for laparoscopic cholecystectomy in otherwise healthy patients and offers better postoperative pain control than general anesthesia without limiting the recovery.

Implementing Standardized Post-Intensive Care Syndrome Education by an Advanced Practice Registered Nurse in the Pediatric Intensive Care Unit

There are approximately 250 000 children admitted annually to critical care units,1 with improved patient outcomes owing in part to advances in technology and clinical management. Despite these advancements, hospitalization-related factors, such as post-intensive care syndrome (PICS), negatively impact patient outcomes. Post-intensive care syndrome is a complex and common result of a patient’s admission to the intensive care unit (ICU) and can occur within 2 days after a patient receives critical care.2 Post-intensive care syndrome has been defined within the adult population; however, there is not a standardized diagnosis in the pediatric population. Children admitted to critical care units are predisposed to several risk factors of PICS, including endotracheal intubation and mechanical ventilation, that can cause cognitive, emotional, or physical dysfunction. In addition, medications used to assist with safe and effective critical care interventions have been shown to cause exacerbation of delirium, depression, dependence, withdrawal, anxiety, bowel dysfunction, and potential neurodevelopmental abnormalities in the pediatric population.3 Although PICS does not affect every child admitted to the pediatric ICU (PICU), more than 50% of patients will suffer from a cognitive or physical component of PICS.1The identification and anticipation of PICS is an essential part of nursing care. Post-intensive care syndrome can affect patients throughout the lifespan, from premature infants to older adults, and manifests as both physical and cognitive symptoms. Patients may experience one of these symptoms or several symptoms concurrently. Physical symptoms may include fatigue, muscle weakness, and insomnia, whereas emotional symptoms may include anxiety, depression, and posttraumatic stress disorder. Cognitive symptoms may manifest as forgetfulness, poor concentration, decreased memory, and difficulty with organization and processing.2 Advanced practice registered nurse (APRN) leaders can provide PICS education to ensure nurses and caregivers will be able to identify and anticipate symptoms, if they arise.A few studies have demonstrated that pediatric patients develop similar symptoms as adults with PICS and can exhibit cognitive, emotional, and physical impairment after an ICU stay.4-6 In addition, caregivers are susceptible to a related syndrome, termed PICS-family. Similar to adult and pediatric ICU patients, caregivers with PICS-family can experience symptoms such as anxiety, depression, and posttraumatic stress disorder for months to years after a child’s ICU admission.7Efforts have been made nationally to support adult ICU patients and caregivers who present with PICS symptoms. One example of an adult intervention for PICS is a interdisciplinary clinic at our academic medical center. The Post-Intensive Care Longitudinal Survivor Experience Clinic is interdisciplinary and includes physicians, social workers, and pharmacists. Although the team does not include a registered nurse or an APRN at this time, this clinic is designed to partner with the patient and the caregiver to coordinate care and provide guidance after discharge. Patients are given a brochure upon ICU discharge that outlines signs and symptoms of PICS and resources available in the community for those experiencing symptoms (see Figures 1 and 2). Examples of resources are YouTube videos, community support programs, and information on how to contact the Post-Intensive Care Longitudinal Survivor Experience Clinic.Post-intensive care syndrome is a relatively new umbrella term for many diagnoses. Therefore, the signs and symptoms of PICS may be unknown and unexpected for nurses and caregivers of pediatric patients. National education initiatives for caregivers regarding PICS are currently focusing outreach efforts at the time of patient discharge. However, if education begins during admission, there is opportunity for nurses to support patients and caregivers throughout the inpatient stay. By engaging caregivers in education and interventions such as early mobility and delirium prevention, the caregiver is able to partner with frontline nurses in the patient’s journey through the ICU. Early caregiver education and awareness are needed to properly prepare the caregiver for challenges that may occur or continue after discharge and to optimize the well-being and recovery of the pediatric patient after critical illness. Because of their expansive clinical knowledge, expertise in patient education, and experience in caring for critically ill patients, APRNs are well positioned to provide anticipatory guidance and education related to PICS.One APRN-led initiative piloted 3 different interventions in the pediatric ICU to educate caregivers on PICS7: a brochure, an in-person conversation, and a prerecorded video. Of the 62 included participants, the preintervention study data demonstrated the caregivers had poor knowledge of PICS. Postintervention analysis showed an increase in caregiver knowledge of PICS with all 3 interventions. However, the use of a brochure was assessed to be the most successful, as it was a resource for the caregiver to keep with them and was feasible for the bedside nurse to deliver during their shift.7 This research study provided a foundation for a quality improvement project implemented by an APRN team at our academic medical center.Because of the absence of a nurse in the Post-Intensive Care Longitudinal Survivor Experience Clinic team, an APRN-led quality improvement initiative was implemented to create an educational brochure, “Staying on the Road to Feeling Better: After an ICU Stay” (see Figures 1 and 2), for the caregivers of PICU patients. An existing PICS brochure was adapted by a team of pediatric APRNs to meet the needs of the PICU population. The APRN team consisted of a clinical nurse specialist, an acute care pediatric nurse practitioner doctor of nursing practice student, and doctorally prepared pediatric nurse practitioner faculty. The team modified and edited the content of the brochure for an age-appropriate approach, as infants and toddlers do not exhibit the same signs and symptoms of PICS as school-aged children or adolescents.The educational initiative began with a virtual presentation via Zoom that was provided to PICU nurses weekly over a 4-week period. Each week, the APRN student would send out an invitation via email for the PICU nurses to join the educational meeting. This weekly virtual meeting consisted of an overview of PICS, the effects this syndrome has on the pediatric critical care population, and a review of the brochure that was created for patients’ caregivers (see Figures 1 and 2). This structured approach prepared the nurse to answer caregiver questions related to PICS prior to implementing use of the brochures for PICS education with caregivers.In recent months, we completed an initial feasibility evaluation regarding the novel PICS education in our 32-bed PICU. Seven bedside nurses completed a survey on how daily work-flow was affected and education was perceived. Survey questions revealed that all 7 nurses responded “Strongly Agree” or “Agree” that they had read the material, teaching families took less than 7 minutes and did not interrupt workflow, and the educational brochure was easy to introduce to caregivers. Nurses indicated that the PICU brochure was feasible and useful as a standardized bedside PICS educational tool for caregivers.The brochure was demonstrated to be useful in a small population of 7 nurses. Future work that focuses on standardizing PICS anticipatory guidance and education during admission will allow further evaluation of the feasibility of the intervention for nurses during their busy shifts. One of the strengths of this initiative is that by partnering with the bedside nurse, the child’s caregiver can receive the PICS education during admission, have time to ask clarifying questions, and speak with various members of the care team regarding discharge planning and long-term effects of PICS. A child’s PICU admission can have long-term physical, emotional, and cognitive effects on the patient and the caregiver. With the implementation of standardized education, caregivers can be more prepared for the potential effects of a prolonged ICU admission.Development of a pediatric post-intensive care clinic would allow for continuity of care for the child and the caregiver. Provided resources at this clinic can mirror those of the adult clinic at our academic institution, the Post-Intensive Care Longitudinal Survivor Experience Clinic, and include educational videos, community resources, and contact information for the pediatric clinic. A pediatric interdisciplinary clinic, led by an APRN and consisting of a social worker, pharmacist, psychologist, and physician who have clinical expertise in critical care would bridge the gap for children and provide support after discharge as they integrate back into their communities, for example, into school and extracurricular activities. Experts who understand the impact of an ICU admission can provide insight into a child’s recovery from a critical illness, including home care and specialized help at school. Children need consistency in their routines, and having continuity among clinicians, parents, and education could provide a platform for communities to implement wrap-around services for children.During their child’s ICU admission, caregivers are inundated with information. Technology has led us away from printed educational materials, and one of the greatest benefits of the brochure was the ability for the caregivers to reference the resources and information throughout their stay and after discharge. The caregivers are able to take the brochure home after discharge, facilitating their ability to revisit the information as needed. In addition, the paper brochure is a cost-effective intervention, because it can be printed in-hospital and can be edited as needed, as opposed to the cost of supplies and tools needed to make an educational video.7 Other interventions such as an educational video or one-on-one conversation are additional options; however, if the conversation or video is not done at an appropriate time because of caregiver stress or distraction, it can easily be forgotten and cannot be revisited as needed.This quality improvement initiative lays the groundwork for future studies and initiatives regarding APRN-led PICS anticipatory guidance. Standardizing PICS education upon admission facilitates the provision of efficient evidenced-based, preventative education to caregivers with a critically ill child. In doing so, the child and caregiver will have resources that allow the anticipation of potential symptoms following discharge, as well as more importantly the support to optimize healing and recovery after surviving a critical illness. There is a need for more rigorous research regarding PICS as it presents among patients of different ages; this dearth allows a unique opportunity for future collaboration between APRNs with varying roles to improve patient outcomes through the translation of evidence into practice.

Unplanned extubations in the adult intensive care units

Patients require admission to intensive care unit with endotracheal intubation and mechanical ventilation for various reasons. It can last for a short duration or could be prolonged. The endotracheal tube is removed once the underlying problem is resolved and is called planned extubation. Sometimes extubation occurs unintentionally and is called unplanned extuabtion. Unplanned extubation could be accidental or self extubation. There is a potential risk of unplanned extubation as long as the patient remains intubated. As unplanned extubation can lead to catastrophic events, it is ideal to have a weaning protocol in place so that the patients are extubated as soon as they satisfy the extubation criteria. This CME article mainly focuses on the risk factors for unplanned extubation in the adult intensive care unit and the complications associated with it. The strategies for prevention of unplanned extubation has been highlighted at the end.